430710435-5-13-2019-07-CC-MSMS-BC5SNY-20190513140219

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430710435
Report Date: 05/13/2019
Date Signed: 05/13/2019 02:02:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	MONTAGUE DISTRICT/STATE PRESCHOOL		FACILITY NUMBER:	430710435
ADMINISTRATOR:	GINA PEREZ		FACILITY TYPE:	850
ADDRESS:	750 LAURIE AVENUE		TELEPHONE:	(408) 423-1931
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95054
CAPACITY:	120	CENSUS: 32	DATE:	05/13/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Gina Perez		TIME COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mel Matos met with Gina Perez, director, for an unannounced annual/random inspection. LPA notes that the Facility is located on the campus of Montague Elementary School. The State Preschool is located in Rooms 12 & 27 and the District Preschool is located in Rooms 26 & 28. The State Preschool is an AM program and is only in operation from 8:30 AM to 11:30 AM Monday to Friday. The District Preschool is open from 7 AM to 6 PM Monday to Friday. LPA toured the Facility both inside and outside during today's inspection. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus, and Activity Schedule. The Facility has three waivers on file for electronic sign in and sign out, shared bathroom usage, and shared playground use. The Facility is in compliance with the terms and conditions of all waivers. The program is operated by the Santa Clara Unified School District and all criminal background checks for staff are handled by the Department of Education and thus do not come under the jurisdiction of Community Care Licensing Division. LPA reviewed ten children's and four staff files (1 director & 3 teachers) during today's inspection. Each child's file reviewed contains the Information and Emergency Information form (LIC 700). The teacher files reviewed contain the required transcripts/verification of experience. Gina and the teachers have current CPR and First Aid certifications on file. Gina understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). LPA observed that the teacher/child ratio was in compliance during today's inspection. Gina understands the conditions, limitations, and capacity specifications of the Facility license. Gina understands that children shall be visually supervised at all times. LPA observed the director & two teachers in Room 28 with 24 preschool children and one teacher with 8 preschool children in Room 26 during today's inspection The State preschool is Title V funded and thus must comply with Title V ratio requirements at all times. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 05/13/2019):

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MONTAGUE DISTRICT/STATE PRESCHOOL	FACILITY NUMBER: 430710435
	VISIT DATE: 05/13/2019

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/13/2019):

LPA observed that all rooms are clean and safe for all children and staff. LPA observed dirty/dusty ceiling air vents and wall air returns in Rooms 12, 26, 27, & 28 during today's inspection. Gina states that the school district provides the staff to clean the Facility Monday through Friday. Drinking water is readily available for the children in each room and in the outdoor playground area via drinking fountains and water jug/disposable cups. LPA observed solid waste containers with tight-fitting lids in each classroom. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Gina states that there are no weapons or firearms on the premises.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Cleaning supplies are inaccessible to the children and stored in high cabinets inaccessible to children. Gina states that the Facility does not administer any medications.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground areas utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. The playground area, located behind Room 28, can accommodate up to 64 preschool children; however, the only shaded areas are located on the left side of the storage shed and near the chain link fenced area facing the parking lot. Thus, there is insufficient shade in the playground area, located behind Room 28. LPA did not observe any bodies of water.

The following Type B deficiencies are noted on the attached page (809-D):

LPA conducted an exit interview with Gina and provided her with the appeal rights prior to the conclusion of today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MONTAGUE DISTRICT/STATE PRESCHOOL	FACILITY NUMBER: 430710435
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/31/2019 Section Cited CCR 101238(a)	1 2 3 4 5 6 7	Buildings & Grounds: The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Gina agreed to have all air vents and wall /ceiling air returns cleaned of all dirt & dust by Friday May 31, 2019. Gina agreed to submit pictures to
	8 9 10 11 12 13 14	LPA Matos observed dirty/dusty ceiling air vents and wall air returns in Rooms 12, 26, 27, & 28 during today's inspection. This presents a potential risk to the health & safety of children in care.	8 9 10 11 12 13 14	LPA Matos verifying completion of the Plan of Correction by Friday May 31, 2019.
Type B 05/31/2019 Section Cited CCR 101232.2(b)(1)	1 2 3 4 5 6 7	Outdoor Activity Space: The outdoor activity space shall be situated to provide a shaded rest area for the children. This requirement is not met as evidenced by: LPA Matos observed that there is	1 2 3 4 5 6 7	Gina agreed to designate 1-2 additional areas of the playground area, located behind Room 28, as shaded rest areas by Friday May 31, 2019.
	8 9 10 11 12 13 14	insufficient shade in the playground area, located behind Room 28, has insufficient shade areas for the preschool children. This presents a potential risk to the health & safety of children.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2019

LIC809 (FAS) - (06/04)

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